Traumatic Knee Dislocations: Evaluation, Management, and Surgical Treatment

Do Age and Timing Influence the Outcomes of Single-stage Reconstruction of Multiple Ligament Knee Injuries? 5-10 Years Follow Up

OBJECTIVES

Multiple ligament knee injuries (MLKIs) are disruptive injuries, however, there are controversies in the results of acute and delayed reconstruction. Also, clinical outcomes between patients older or younger than 40 have not been compared in MLKIs. This study was designed to investigate the influence of age and timing of reconstruction on the outcomes of single-stage reconstruction of MLKIs.

METHODS

The patients who underwent reconstruction of multiple injured ligaments because of MLKIs between May 2013 and July 2019 were added to the cohort. The postoperative complications, knee range of motion (ROM), Lysholm score, International Knee Documentation Committee (IKDC) 2000 score, Tegner activity level, patient satisfaction, and SF-36 score were compared between young (≤ 40 years old, n = 41) and old patients (n = 61); acute (≤ 3 weeks after injury, n = 75) and delayed reconstruction (n = 27), using Mann-Whitney U test or χ2 test.

RESULTS

A total of 102 MLKI patients managed by single-stage multi-ligament reconstruction were retrospectively reviewed. Patients were followed up after surgery for a mean of 7.3 years (5.2-10.7 years). At the last follow-up, no significant difference was found in knee ROM, functional scores, and patient-reported outcomes between patients older or younger than 40; acute and delayed reconstruction (p > 0.05). The rate of complications in the delayed reconstruction group was higher than that of the acute reconstruction group (22.2% vs 5.3%, p < 0.05). The IKDC objective scores reached grade A in 63.7%-80.4% of patients, and grade B in 11.8%-23.5% patients.

CONCLUSION

The single-stage reconstruction of MLKIs can obtain comparative long-term functional and objective outcomes regardless of patients older or younger than 40; acute and delayed reconstruction, however, delayed reconstruction is related to a high rate of postoperative complications.

Tibiofemoral Dislocation Management in a Rural High School Football Scenario: Development of a Popliteal Artery Injury Suspicion Index

OBJECTIVE

This study evaluated the knowledge and preparedness of athletic trainers (ATs) for diagnosing and managing an anterior tibiofemoral knee dislocation in a rural or limited-resource high school football setting scenario. The study hypothesis was that more experienced ATs would display greater preparedness than less experienced ATs. A secondary objective was to develop evidence-based guidelines to help the AT provide better emergency triage care.

METHODS

This prospective cross-sectional study distributed a rural high school football game scenario survey electronically to a random sample of 2000 certified ATs to determine their perceptions of readiness to diagnose and manage an anterior tibiofemoral knee dislocation with signs or symptoms of possible popliteal artery injury.

RESULTS

A total of 249 surveys (12.5%) were completed. Years of athletic training experience were ≤5 years (n = 82, group 1) and ≥6 years (n = 167, group 2). Both groups perceived that they could not "rule out" an arterial injury and had similar "red flag" sign and symptom rankings. Group 2 perceived a more serious situation than group 1 (77.5 ± 15 vs 70.8 ± 14, P < 0.0001) and were more likely to activate the emergency action plan (74.5 ± 25 vs 64.4 ± 26, P = 0.005). Both groups were "neutral" about their ability to diagnose the condition or manage the case, had poor ankle-brachial index test familiarity, and agreed that evidence-based guidance was needed.

CONCLUSIONS

More experienced ATs perceived a more serious situation than less experienced ATs and were more likely to activate the emergency action plan. Both groups were neutral about their ability to diagnose the condition or manage the case, had poor ankle-brachial index test familiarity, and agreed that they would benefit from evidence-based guidance. Proposed guidelines provide the AT with a more measured, evidence-based index of suspicion for potential popliteal artery injury in anterior tibiofemoral dislocation cases. This will complement existing hospital emergency department-based management algorithms, decreasing the likelihood of this condition progressing to limb loss or death.

German S2e-Guideline "Knee Dislocation"

Knee dislocation is a devastating form of multiligament injury of the knee. Due to its high complexity, there is a large number of different diagnostic and treatment strategies. With the aim of providing evidence-based treatment recommendations, the S2e guideline on knee dislocation is aimed at all professional groups involved in diagnostics and therapy (orthopaedic and trauma surgeons, physiotherapists, outpatient/inpatient surgeons, sports physicians, etc.) as well as those affected (patients with knee dislocation) and service providers (health insurance companies, pension insurance companies). In addition to the presentation of conceptual differences between the injury entities, this includes the special features of diagnostic testing, options for conservative and surgical therapy as well as aspects of follow-up treatment - against the background of the interdisciplinary treatment approach to a severe knee injury.

Outcomes of multiligament knee injury treated with versus without internal brace suture augmentation

PURPOSE

To compare the postoperative outcomes between Internal Brace (IB) and non-IB patients who underwent surgical management of multiple-ligament knee injuries (MLKI).

METHODS

Patients who underwent surgical management of MLKI at two institutions between 2010 and 2020 were identified and offered participation in the study via the collection of postoperative functional outcomes for MLKI; Lysholm Knee score, Multiligament Quality of Life (ML-QOL), Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive testing (CAT), Pain Interference (PI), Physical Function (PF), and Mobility instruments (MI). The postoperative outcomes and reoperation rates were compared between the IB group and non-IB group.

RESULTS

One hundred and twenty-six patients were analyzed; 89 were included in the IB group (31.5% female; age 35.6 ± 1.4 years), and 37 were included in the non-IB group (25.7% female; age 38.8 ± 2.4 years). Mean follow-up time of the entire cohort was 37.9 ± 4.7 months [IB: 21.8 + 1.63; non-IB: 76.4 ± 6.2, p < 0.001). The IB group achieved similar PROMIS CAT [PROMIS Pain (51.8 + 1.1 vs. 52.1 + 1.6, p = 0.8736), Physical Function (46.6 + 1.2 vs. 46.4 + 1.8, p = 0.9168), Mobility (46.0 + 1.0 vs. 43.7 + 1.6, p = 0.2185)], ML-QOL [ML-QOL Physical Impairment (36.6 + 2.5 vs. 43.5 ± 4.2, p = 0.1485), Emotional Impairment (42.5 + 2.9 vs. 48.6 ± 4.6, p = 0.2695), Activity Limitation (34.5 + 2.8 vs. 36.2 ± 4.3, p = 0.7384), Societal Involvement (39.1 + 3.0 vs. 41.7 + 4.2, p = 0.6434)] and Lysholm knee score (64.9 + 2.5 vs. 60.4 + 4.0, p = 0.3397) postoperatively compared the non-IB group, but the differences were not significant.

CONCLUSION

In this cohort of patients with MLKI treated with versus without IB, outcomes and reoperation rates trended toward favoring IB, but the study was not sufficiently powered to reach statistical significance. Internal bracing could be useful in the management of MLKI. In the future, matched patient cohorts with more patients are warranted to further evaluate the clinical impact of the internal brace in MLKI.

Characteristics of multi-ligament knee injuries accompanied with patellar tendon disruption

PURPOSE

Patella tendon rupture with multi-ligament injury is a rare injury. We observed patients with patella tendon rupture (or patella inferior pole fracture) with multi-ligament injury. This study intends to inspect the mechanism of the injury and classify them.

METHODS

This is a case series involving patients from two hospitals. Twelve patients who had patella tendon rupture (PTR) with multi-ligament injury were studied.

RESULTS

The incidence of multi-ligament injury in patella tendon rupture patients found to be 13% in retrospective search. Two types of injury were observed. First type is relatively low energy injury involving ACL and patella tendon which does not involve rupture of PCL. Second type is high energy injury involving PCL and patella tendon. Treatment differed among the patients, due to severity of trauma. Two-staged operation was the basis of treatment. Patella tendon was repaired in first stage. Reconstruction of ligaments was done in second stage. The patients who had infection or stiffness did not have a second surgery.

CONCLUSION

Patella tendon rupture with multi-ligament injury can be classified into low energy rotational injury and high energy dashboard injury. Two-staged surgery is the basis of treatment.

Team Approach: Treatment of Traumatic Dislocations of the Knee

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Traumatic knee dislocations are complex injuries that can be associated with compromise of the neurovascular structures about the knee.

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Various classification systems for knee dislocations exist in the literature but should be used with caution as a prognostic tool because many knee dislocations fit into more than 1 category.

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Special populations of knee dislocations, such as obese patients and high-velocity mechanism injuries, require additional caution during the initial evaluation for possible vascular injuries.

Traumatic Bifocal whereas and Ipsilateral Posterior Knee Dislocation: A Case Report

CASE

A 19-year-old man sustained combined, ipsilateral inferior hip and posterior knee fracture-dislocations secondary to a motor vehicle collision. He underwent immediate closed reduction of the knee and delayed open reduction internal fixation but required emergent open hip reduction for an irreducible femoral head incarcerated on a pubic root fracture. At the 1-year follow-up, he demonstrated excellent functional outcome with painless and full hip and knee range of motion.

CONCLUSION

Irreducible inferior femoral head dislocation in combination with a knee dislocation requires thoughtful staging and treatment but can result in satisfactory outcomes.

Complex Repair and Cruciate Ligament Reconstruction in KDs III and IV Multiligamentous Knee Injuries-Results of Mid-Term Follow-up

The purpose of the present study was to describe the longitudinal outcomes of acute repair of extra-articular structure and anatomical reconstruction of cruciate ligament for knee dislocations (KDs) III and IV multiligamentous knee injuries. Forty-seven patients with an acute KD III or IV were treated with one-stage management within 9.2 days. Forty-five KDs III and IV with a follow-up at a mean of 53.2 months were evaluated. The mean International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner score were 81.5 ± 0.7, 89.6 ± 1.2, and 6.8 ± 0.5, respectively. Comparing preoperative data with those at the latest follow-up, significant improvements in IKDC score (p < 0.01), Lysholm score (p < 0.01), and Tegner score (p < 0.01) were noted in all groups. Comparing contralateral knee stability, no statistical differences were found including the varus/valgus (0 degree/30 degrees) and Telos stress radiography. So, acute repair of extra-articular structure and anatomical reconstruction of cruciate ligament resulted in satisfactory outcomes for KDs III and IV multiligamentous knee injuries.

Acute Femoropopliteal Bypass Graft Occlusion After Knee Manipulation Under Anesthesia: A Case Report and Review of Current Literature

Bilateral tibiofemoral knee dislocations are a relatively rare injury, and there is a scarcity of literature on its appropriate evaluation and treatment. Even less knee dislocations with concomitant popliteal artery injury have been described. Postoperative graft occlusion accounts for approximately half of the overall complication rate, occurring in up to 18% of the patients undergoing femoropopliteal bypass grafting. Furthermore, anticoagulation and antiplatelet therapy after graft placement is a point of contention. Here, we describe a case of a knee dislocation with associated popliteal artery transection treated initially with successful knee-spanning external fixation and arterial grafting, respectively. At 6 weeks after injury, the patient underwent external fixation removal and closed manipulation of the knee for arthrofibrosis. After manipulation, yet still under anesthesia, distal pulses were acutely diminished and subsequent CTA demonstrated femoropopliteal graft thrombosis. This case demonstrates successful recognition, thrombectomy, and restoration of arterial blood flow, which has since been maintained. Written consent by the patient involved in this case report was obtained.

Management of acute knee dislocation with vascular injury: the use of the external fixator. A systematic review

INTRODUCTION

Vascular injuries after traumatic knee dislocation pose a potential limb threat for the patient. The benefits of external fixation have been described by many authors. However, the usefulness of the external fixator during acute management of knee dislocations with vascular injuries is a controversial aspect that has no consensus in the literature. The purpose of the present study was to provide data from the current literature on the utility of the external fixator and to investigate the percentage of knee dislocations with vascular injuries treated with an external fixator, the timing between external fixator and vascular repair, and the total time of external fixator.

MATERIAL AND METHODS

The present systematic review was conducted according to the PRISMA checklist. MEDLINE (Pubmed), Web of Science, and SCOPUS databases were searched for articles from 1 January 2000 to 6 February 2019. Studies reporting outcomes of treatment of knee dislocations with vascular injuries were included. Exclusion criteria included studies investigating chronic knee dislocations, knee arthroplasties, editorials, case reports, and expert opinions. Two authors independently extracted data and appraised the quality of evidence and risk of bias using the Methodological quality and synthesis of case series and case reports.

RESULTS

Descriptive statistics were used to report the outcome of our findings. Seven studies related to the usefulness of the external fixator during acute management of knee dislocations with vascular injuries were included. The external fixator had been used in the majority of knee dislocations with vascular lesions (72%). Timing between external fixator and vascular repair was reported on four studies (57%), two studies performed external fixation before vascular repair, and two studies performed external fixation after vascular repair. Total time of external fixator was only reported on three studies, ranging from 3 weeks to 3 months. These studies reported acute management, without referring to long-term results and without comparative groups.

CONCLUSIONS

External fixator was used in the majority of knee dislocations with vascular injuries but the justification for its use remained unclear. Larger studies are needed to fully understand the merit of the external fixator in knee dislocations with vascular injuries. Joint protocols between vascular surgeons and trauma surgeons are necessary to agree on the aspects related to the management of knee dislocations with vascular injuries.

LEVEL OF EVIDENCE

IV.

The accuracy of MRI in diagnosing and classifying acute traumatic multiple ligament knee injuries

Background

Magnetic resonance imaging (MRI) is widely used for the evaluation of knee injuries, however, the accuracy of MRI in classifying multiple ligament knee injuries (MLKIs) remains unknown. This study aimed to investigate the accuracy of MRI in diagnosing and classifying acute traumatic MLKIs, we hypothesize that MRI had high accuracy in detecting and classifying MLKIs.

Methods

The clinical data of 97 patients who were diagnosed with acute traumatic MLKIs and managed by multi-ligament reconstruction between 2012 and 2020 were retrospectively reviewed. The MR images were read by two experienced radiologists and results were compared with intraoperative findings, which were considered as the reference for the identification of injured structures. The value of MRI in detecting injuries of anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), lateral collateral ligament (LCL), and meniscus was evaluated by calculating the sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio, and kappa coefficients analysis. The value of MRI in classifying MLKIs was evaluated by calculating the agreement between MRI and intraoperative findings.

Results

For detecting the specific injured structures in MLKIs, MRI had high sensitivity (90.7% for ACL, 90.4% for PCL, and moderate specificity (63.6% for ACL, 50% for PCL) in detecting cruciate ligament injuries, moderate sensitivity (79.1% for MCL, 55.6% for LCL) and specificity (46.7% for MCL, 68.4% for LCL) in detecting collateral ligament injuries, fair sensitivity (61.5%) and low specificity (39.4%) in the diagnosis of injuries to the meniscus. For classifying the MIKIs, MRI had a moderate agreement with intraoperative findings in classifying KD-V (kappa value = 0.57), poor agreement in the KD-I (kappa value = 0.39) and KD-IIIM (kappa value = 0.31), meaningless in the KD-II and KD-IIIL (kappa value < 0). The overall agreement between MRI and intraoperative findings in classifying MLKIs was poor (kappa value = 0.23).

Conclusions

MRI is valuable in early detection and diagnosis of acute MLKIs, however, the accuracy of MRI in classifying MLKIs is limited. The management of MLKIs should be based on intraoperative findings, physical examinations, and comprehensive imaging results.

Two years neglected knee dislocation: An unusual case report

INTRODUCTION

Traumatic dislocation of the knee is a rare and severe injury, often caused by a severe trauma. Neglected knee dislocations are much more uncommon and treatment options are not clearly described.

PRESENTATION OF CASE

We reported the case of a 26-year-old man with two years neglected knee dislocation which was managed with open reduction and stabilization with external fixation and intra-articular Steinman pins for six weeks.

DISCUSSION AND CONCLUSION

Knee dislocations are rare injuries that can be underestimated during the emergency assessment, particularly in the absence of neurovascular injuries, which usually lead to surgical treatment, or the presence of severe trauma that disguises dislocation as the case for our patient. Only a high clinical suspicion can avoid neglecting the more severe joint injury.

Current concepts in the assessment and management of multiligament injuries of the knee

Multiligament knee injuries (MLKIs), though rare, pose significant challenges to the patient and surgeon. They often occur in the setting of high-velocity trauma and are frequently associated with concomitant intra- and extra-articular injuries, the most immediately devastating of which is vascular compromise. A detailed evaluation is required when acute or chronic MLKIs are suspected, and stress radiography, MRI and angiography are valuable adjuncts to a thorough clinical examination. Surgical treatment is widely regarded as superior to non-surgical management and has been demonstrated to improve functional outcome scores, return to work, and return to sport rates, though the incidence of post-traumatic osteoarthritis remains high in affected knees. However, acceptable results have been obtained with conservative management in populations where surgical intervention is not feasible. Early arthroscopic single-stage reconstruction is currently the mainstay of treatment for these injuries, but some recent comparative studies have found no significant differences in outcomes. Recent trends in the literature on MLKIs seem to favour early surgery over delayed surgery, though both methods have distinct advantages and disadvantages. Due to the heterogeneity of the injury and the diversity of patient factors, treatment needs to be individualised, and a single best approach with regards to the timing of surgery, repair versus reconstruction, surgical technique and surgical principles cannot be advocated. There is much controversy in the literature surrounding these topics. Early post-operative rehabilitation remains one of the most important positive prognostic factors in surgical management and requires a dedicated team-based approach. Though outcomes of MLKIs are generally favourable, complications are abundant and precautionary measures should be implemented where possible. Low resource settings are faced with unique challenges, necessitating adaptability and pragmatism in tailoring a management strategy capable of achieving comparable outcomes.

MRI of Traumatic Knee Dislocation: A Study to Evaluate Safety and Image Quality for Patients with Knee-Spanning Stabilization Devices

This study evaluated safety and image quality of MRI exams performed for patients with traumatic knee dislocations in knee-spanning stabilization devices. It is an IRB-approved retrospective design with waived informed consent that included 63 patients with traumatic knee dislocation. 56 patients had metallic external fixators, and 7 patients had non-metallic knee immobilizers. 7 patients had bilateral dislocations yielding a total of 70 knee MRIs. 1.5 Tesla MRI exams were performed for all patients who were awake and alert at the time of imaging. All knee-spanning external fixators were considered "MR conditional" by the FDA. The electronic medical record was reviewed for notes from the technologist and nursing staff documenting any patient complaints or adverse events during the MRI exam as required by departmental protocol. Qualitative analysis of the six most frequently performed sequences were independently conducted by 2 musculoskeletal radiologists using a 5-point Likert scale. Overall image quality and select time intervals between the two groups were compared using an independent sample t test and the Mann-Whitney U test, respectively. No adverse events were reported for a 40-minute average estimated patient scan time with the stabilization devices in the MR gantry. Mean values of Likert scale scores were generated from two readers' data for comparison between the external fixation and the immobilizer groups. Most knee MRI exams with external fixators were within diagnostic quality despite artifacts (grade 3). MRI exams generally were of higher diagnostic quality in the immobilizer group than the external fixator group (p < 0.05). The external fixator models included DePuy Synthes, Smith and Nephew, Stryker Hoffman III, Zimmer FastFrame, and Zimmer XtraFix. MRI examinations in patients with external fixators for traumatic knee dislocations can be safely performed under certain conditions and provide diagnostic quality images.

A systematic review comparing the results of early vs delayed ligament surgeries in single anterior cruciate ligament and multiligament knee injuries

PURPOSE

The purpose of this study was to compare clinical outcomes and incidence of concomitant injuries in patients undergoing early vs delayed surgical treatment of single anterior cruciate ligament (ACL) injury and multiligament knee injury (MLKI).

METHODS

A literature search using PubMed, Embase, the Cochrane Library, the Cumulative Index to Nursing and Allied Health, and Scopus from their inception to April 30, 2020 was conducted. Studies with levels I to IV evidence reporting the incidence of meniscus or cartilage injury according to early vs delayed surgery in single ACL injuries and MLKIs were included. In the meta-analysis, data based on the number of meniscus and cartilage injuries were extracted and pooled. Lysholm and Tegner scores were analyzed using two-sample Z-tests to calculate the non-weighted mean difference (NMD). A meta-regression analysis was also performed to determine the effect of single ACL injury and MLKI/study design.

RESULTS

Sixteen studies on single ACL injury and 14 studies on MLKI were included in this analysis. In the analysis, there were significant decreases in Lysholm score (NMD - 5.3 [95% confidence interval (CI) - 7.37 to - 3.23]) and Tegner score (NMD - 0.25 [95% CI - 0.45 to - 0.05]) and increases in risk of meniscus tear (odds ratio [OR] 1.73 [95% CI 1.1-2.73], p = 0.01) and cartilage injury (OR 2.48 [95% CI 1.46-4.2], p = 0.0007) in the delayed surgery group regardless of single ACL injury or MLKI. The result of the meta-regression analysis indicated that single ACL injury and MLKI/study design were not significant moderators of overall heterogeneity (p > 0.05).

CONCLUSIONS

Our study suggests that delayed ACL surgery significantly resulted in a higher risk of meniscus tear and cartilage injury and decreased Lysholm and Tegner scores compared to early ACL surgery. The Lysholm scores in the delayed MLKI surgery group were significantly decreased, but the risks of meniscus tear and cartilage injury in the delayed MLKI surgery group remained unclear.

LEVEL OF EVIDENCE

Level III, meta-analysis.

Distal biceps femoris avulsions: Associated injuries and neurological sequelae

BACKGROUND

The aim of this study was to describe associated injuries in cases of distal biceps femoris avulsions (DBFA) as well as the incidence of neurological injury and radiographic abnormalities of the common peroneal nerve (CPN).

METHODS

A retrospective chart review was conducted of patients presenting to our office or trauma center with DBFA injuries. Demographic data was obtained as well as mechanism of injury. Assessment of concomitant injuries and presence of neurologic injury was completed via chart review and magnetic resonance imaging (MRI) review. The CPN was evaluated for signs of displacement or neuritis.

RESULTS

Sixteen patients were identified (mean age-at-injury 28.6 years, 87.5% male) with DBFA. Three patients (18.8%) sustained their injuries secondary to high energy trauma while 13 (81.3%) had injuries secondary to lower energy trauma. Nine patients (56.3%) initially presented with CPN palsy. All patients presenting with CPN palsy of any kind were found to have a displaced CPN on MRI and no patient with a normal nerve course had a CPN palsy.

CONCLUSIONS

This case series demonstrates a strong association between DBFA and CPN palsy as well as multi-ligamentous knee injury (MLKI). These injuries have a higher rate of CPN palsy than that typically reported for MLKI. Furthermore, these findings suggest that CPN displacement on MRI may be a clinically significant indicator of nerve injury. LOE: IV.

Internal Neurolysis of the Common Peroneal Nerve With Lower Extremity Flexion Increases Likelihood for Direct End-End Nerve Repairs

Introduction

An understanding of common peroneal neuropathy is essential to improving current surgical techniques and overcoming limitations of permanent common peroneal nerve (CPN) damage, which negatively impacts quality of life. This study focuses on quantifying additional nerve length after CPN internal neurolysis with varying degrees of lower extremity flexion, in order to improve end-end nerve repairs in the setting of injury with a significant gap.

Materials and methods

Full and partial neurolysis dissections were performed on salt- and formaldehyde-perfused cadavers. For accurate measurement of additional length obtained, all dissections were palpated at the fibular head and CPNs transected proximally at the distal fascial border. We chose this site to measure the nerve length obtained because it is the common site for CPN injury and the most clinically applicable. The amount of nerve length gained from neurolysis alone was measured at the location of the common peroneal nerve passing deep to peroneus longus before and after being transected. Nerve length after neurolysis was measured in cm at 10° increments, using a protractor starting at 90° and ending at 0°.

Results

Both formaldehyde- and salt-perfused cadavers have a significant difference in nerve length obtained after neurolysis at each angle of measurement. This is seen for both dissection groups with p-values <0.05.

Conclusions

In this study, we found a direct statistically significant relationship between extent of neurolysis and increased angle of measurement, to amount of addition nerve length obtained in both neurolysis groups despite fixation type.

Controversies in acute multiligamentary knee injuries (MLKI)

Multiligament injuries of the knee (MLKI), remain an infrequent pathology especially in developed countries compared to mono-ligament lesions. In Colombia, MLKI is frequent due to the high accident rate on motorcycles. In the city of Bogota alone, about 160 motorcycle accidents have been estimated daily, being one of the cities that proportionately use this means of transport less compared to small cities. The term MLKI, include all ruptures of two or more major ligaments and therefore it has a broad spectrum of clinical presentation which creates a great challenge for the orthopedists and the surgeons envolved in this topic. The literature is rich in studies level IV but very poor in level I and level II, which generates controversies and little consensus in the diagnosis and treatment of this pathology. However there has been a gradual and better understanding of all factors involved in the treatment of MLKI that has improved the functional results of these knees in our patients, in fact we currently are more precise to achieve accurate diagnosis, evolved from not surgical approach to operate most, applying new anatomical and biomechanical concepts, with specialized and skill surgical techniques with more stable and biocompatible fixation implants, which allow in most cases to initiate an early integral rehabilitation program. Nevertheless due to the complexity and severity of the lesions, in some patients the functional results are poor. The goal of this revision is to identify the most frequent controversies in the diagnosis and treatment of MLKI, defining which of them are agreed according to what is reported in the literature and share some concepts based from the experience of more than 25 years of the senior author (MM) in the management of these injuries. LEVEL OF EVIDENCE: V - Expert Opinion.

The outcomes of one-stage treatment for multiple knee ligament injuries combined with extensor apparatus rupture

Background

Multiple knee ligament injuries combined with extensor apparatus rupture are serious and complex knee injuries that are rare in clinical practice. The management is extremely challenging and controversial.

The aim of this study is to describe a patient collective with multiple knee ligament injuries combined with extensor apparatus injuries in detail and to report the mid-term outcomes of a one-stage surgical treatment regarding subjective outcome scores, complications, knee instability, and ROM.

Methods

Eleven of 425 patients with multiple knee ligament injuries combined with extensor apparatus injuries admitted to our hospital were reviewed from July 2008 to May 2017. All patients underwent one-stage repair and reconstruction of multiple knee ligaments and extensor apparatus. The Lysholm knee score and the International Knee Documentation Committee (IKDC) score were adopted to evaluate the surgical effect preoperatively and at a minimum of 2 years’ follow-up. Clinical data, including range of motion and knee stability, were also recorded at the final follow-up.

Results

Ten patients were followed up with a mean time of 40 (range, 24–60) months. At the last follow-up, 8 patients had joint flexion range of motion greater than or equal to120 degrees, 2 patients had joint flexion range of motion of 100–120 degrees, and 1 patient had active knee extension limitation of 5 degrees. Stress radiographs showed that the mean differences in posterior displacement were reduced from 10.8 ± 3.0 mm preoperatively to 2.0 ± 2.5 mm at the last follow-up. There were significant improvements in stress radiographs from pre- to postoperative states for all patients with multiple knee ligament injuries. The Lysholm score ranged from 85 to 96, with a mean of 92.1 (compared with 33 before surgery, P < 0.05). The final IKDC scores were A in 2 patients (20%), B in 7 (70%), and C in 1 (10%). Nine of the 10 patients (90%) returned to their former activity level.

Conclusion

Multiple knee ligament injuries combined with extensor apparatus rupture are rare. Single-stage management of the repair and reconstruction of multiple knee ligaments and extensor apparatus with proper rehabilitation is an effective and reliable procedure to restore knee stability and function.

Level of evidence

Level IV, therapeutic case series.

Varus mechanism is associated with high incidence of popliteal artery lesions in multiligament knee injuries

PURPOSE

This study aims to identify multiple ligament knee injury patterns that possess a high-risk of vascular lesion.

METHODS

We retrospectively compared torn ligament patterns and the presence of vascular lesions confirmed by magnetic resonance imaging and computed tomography angiography from 122 consecutive patients with diagnoses of multiple ligament knee injury made at the emergency department between January 2012 and December 2017. Patients were not eligible if they had an ipsilateral lower extremity lesion (dislocations or fractures at another level), initial evaluation at another hospital, or follow-up for less than 12 months. The primary outcomes were the comparison between the imaging findings of torn structures patterns and the presence of a vascular lesion.

RESULTS

We identified 48 eligible patients (50 knees) with multiligamentary knee lesions, of whom eight had popliteal artery damage, yielding an incidence of 16%. Our clinical examination detected six of these patients that were classified, according to the Schenck system, as KD-IIIL (6 knees) and KD-IIIM (2 knees). The odds of having a popliteal artery injury is 4.69 to 1 with a KD-IIIL injury that with any other type of injury on that classification (95% CI 0.960-22.98).

CONCLUSIONS

This data suggests that varus forces causing enough energy to produce a KD-IIIL lesion possess a higher popliteal artery injury risk, making recommendable a thorough examination of the vascular integrity when diagnosing a KD-IIIL lesion.

[Application of transosseous suture in situ technique in repair of anterior cruciate ligament for multiple ligament injuries with knee dislocation]

OBJECTIVE

To investigate the method and effectiveness of transosseous suture in situ technique in repairing anterior cruciate ligament (ACL) avulsion injury for the multiple ligament injuries with knee dislocation (MLIKD).

METHODS

The clinical data of 27 patients (27 knees) with MLIKD between September 2010 and April 2016 were analyzed retrospectively. There were 21 males and 6 females, with an average age of 42 years (range, 24-60 years). The injury was caused by traffic accident in 9 cases, heavy-weight crushing in 9 cases, sports sprain in 6 cases, falling from height in 3 cases. The interval from injury to operation was 1-19 days (mean,10.8 days). There were 20 cases of femoral avulsion injury of ACL, 7 cases of tibial avulsion injury of ACL, and there were 17 cases of posterior cruciate ligament (PCL) injuries. According to the Schenck classification, there were 15 cases of KD-Ⅲ-M type, 8 cases of KD-Ⅲ-L type, and 4 cases of KD-Ⅳ type. All patients were positive in the posterior drawer test and Lachman test; 8 cases were degree Ⅲ positive in varus stress test, and 15 cases were degree Ⅲ positive in valgus stress test. The Lysholm score of knee was 27.6±6.5, the International Knee Documentation Committee (IKDC) score was 25.5±6.2, and the range of motion (ROM) of knee was (45.1±10.2)°. The injured PCL was reconstructed with a single bundle of autologous hamstring tendon. ACL was repaired with double bundle traction by transosseous suture in situ technique. Medial cruciate ligament, lateral cruciate ligament, joint capsule, and other damaged structures were repaired at the same time.

RESULTS

All incisions healed by first intention. There were 3 cases with joint effusion and 3 cases with incomplete flexion. All patients were followed up 12-36 months (mean, 22 months). The X-ray films showed good stability in all directions. At last follow-up, the anterior and posterior drawer tests were all negative; Lachman test was degreeⅠpositive in 4 cases, valgus stress test was degreeⅠpositive in 3 cases, varus stress test was degreeⅠpositive in 1 case; and all tests were negative in the rest patients. At 1 year after operation, the ROM of knee was (119.3 ±12.6)°, Lysholm score was 87.2±6.3, and IKDC score was 87.9±6.3, showing significant differences when compared with the preoperative scores ( P<0.05).

CONCLUSION

Transosseous suture in situ technique can be used to repair the ACL avulsion injury for MLIKD, which can significantly improve the stability, mobility and function of the knee joint, and obtain satisfied short-term effectiveness.

Evaluation and Management of Knee Dislocation in the Emergency Department

BACKGROUND

Knee dislocations are a potentially limb-threatening injury, and it is essential that emergency medicine clinicians are aware of them.

OBJECTIVE

This article provides a review of the diagnosis and management of knee dislocation for the emergency provider.

DISCUSSION

Knee dislocations are uncommon injuries with the potential for significant morbidity. A thorough history and examination are important, because 50% of dislocations may have reduced before arrival to the emergency department. Knee dislocations should be quickly reduced in the emergency department setting. The presence of equal pulses does not exclude vascular injury, and all patients should undergo serial vascular examinations and evaluation with ankle-brachial indices. Those with abnormal ankle-brachial indices should receive computed tomographic angiography. Radiographs are important to identify any fractures, while magnetic resonance imaging may be deferred until after admission.

CONCLUSION

Knee dislocation is a potentially dangerous medical condition requiring rapid diagnosis and management. It is essential for emergency clinicians to know how to diagnose and treat this disorder.

Irreducible Posterolateral Fracture Dislocation of the Knee in an Elderly Patient Treated with Rotating Hinge Total Knee Replacement

Knee dislocation is one of the few real orthopaedic emergencies. It is a serious but relative uncommon injury, representing less than 0.02% of all orthopaedic injuries. Especially posterolateral knee dislocation is much rarer condition that is often missed or misdiagnosed. The main feature of this very rare condition is to be irreducible by closed reduction due to the interposition of soft tissues inside the enlarged medial joint space, such as the medial capsule and retinaculum, vastusmedialis, and medial meniscus. The pathognomonic sign of a posterolateral knee dislocation is the anteromedial distal thigh transverse "pucker" or "dimple sign." We report the case of an 87-year-old man who sustained an irreducible posterolateral fracture dislocation of the knee after being hit by car which has been treated with rotating hinge knee replacement with 1-year of follow-up.

Performance of PROMIS Computer Adaptive Testing As Compared With Established Instruments for Multiple-Ligament Knee Injuries

Background:

The Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive testing (CAT) is a patient-reported outcome metric that has been validated for anterior cruciate ligament (ACL) injuries, ACL reconstructions, and meniscal injuries. Thus far, the system has not been validated for multiligament knee injuries. The Multiligament Quality of Life (MLQOL) questionnaire is a validated, disease-specific patient-reported outcome instrument for this population that can serve as a gold standard for validation of the newer PROMIS.

Purpose/Hypothesis:

The purpose of this study was to further validate the PROMIS CAT for multiligament knee reconstruction. We hypothesized that the PROMIS CAT modules would correlate with the Lysholm knee score (Lysholm), Tegner activity scale (Tegner), and MLQOL for postoperative multiligamentous knee injury patients and that the PROMIS CAT would use fewer question items than the Lysholm, Tegner, and MLQOL while still avoiding floor and ceiling effects.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

A total of 30 patients meeting the inclusion criteria were retrospectively identified and agreed to participate (87% male; mean ± SD age, 36.3 ± 13.5 years). Consenting patients were administered the Lysholm, Tegner, MLQOL, and PROMIS CAT for Physical Function, Mobility, and Pain Interference. Spearman correlations were used to test agreement across survey instruments. Floor and ceiling effects were assessed for all instruments.

Results:

PROMIS Pain Interference had excellent correlation with MLQOL Activity Limitations (r = 0.71, P < .0001). Excellent-good correlations were detected between PROMIS Physical Function and MLQOL Activity Limitations (r = –0.63, P = .0002) and PROMIS Mobility and MLQOL Activity Limitations (r = –0.62, P < .0002). Good correlations were found between the Lysholm and the PROMIS Physical Function and PROMIS Mobility (for each, r = 0.50, P = .005). Additional correlations were present with other subsections. There were no floor or ceiling effects for the PROMIS CAT instrument in any category.

Conclusion:

The PROMIS CAT correlates well with existing outcome measures for multiligament knee injury patients without floor or ceiling effects. The PROMIS CAT is a concise adjunct to the validated injury-specific outcome tool for multiligament knee injury. Surgeons should consider implementing the PROMIS CAT because of its broad validity, including ACL injuries, meniscal tears, and now multiligament knee injuries.

Open knee dislocation with a patellar tendon rupture: Result of staged surgical repair

Knee dislocation with concomitant multiligament injury is a rare and devastating injury. We report the successful repair of a rare case of open knee dislocation with concomitant multiligament injury and patellar tendon rupture of an 18-year-old male due to a motorcycle accident. The patient presented with an open wound running parallel to the knee joint line and patellar tendon rupture with full exposure of the cartilage of the distal femur. Staged surgical management including the application of a ring-type external fixator with a hinged joint, lateral collateral ligament repair, medial collateral ligament reconstruction using autogenous hamstring tendon, and joint release was performed. Range of movement was recovered to 0 degrees of knee extension and 80 degrees of knee flexion, and extension lag was negative. The Lysholm score of the patient was recovered to 92. The patient was able to return to work in the construction field 2 years after sustaining the injury. The patient had no complaint of pain and was able to resume construction work, even though reconstruction of the anterior cruciate ligament and posterior cruciate ligament was not performed. The application of a hinged ring-type external fixation device might play a key role in early range of movement restoration and to maintain the reduced position and acceptable recovery of the posterior cruciate ligament injury without the need for reconstructive surgery. This report is the first to describe the safety and effectiveness of staged surgical management for the repair of open knee dislocation with concomitant multiligament injury and patellar tendon rupture. However, further studies with longer follow-up periods will be needed to observe the development of osteoarthritis or weakness of the knee. Staged surgical management is a safe and effective procedure for repairing an open knee dislocation with concomitant multiligament injury and patellar tendon rupture.

The Biomechanics of Multiligament Knee Injuries: From Trauma to Treatment

The multiple ligament injured knee is a complex biomechanical environment. When primary stabilizers fail, secondary stabilizers have an increased role. In addition, loss of primary restraints puts undue stress on the remaining intact structures of the knee. Treatment of these injuries requires accurate diagnosis of all injured structures, and careful consideration of repairs and reconstructions that restore the synergistic stability of all ligaments in the knee.

Association of Injury Energy Level and Neurovascular Injury Following Knee Dislocation

OBJECTIVE

To describe the associations between mechanism of injury energy level and neurovascular injury (NVI) following knee dislocation (KD) using a large representative sample of trauma patients and to examine risk factors within these groups.

DESIGN

Retrospective cohort study.

SETTING

Trauma centers participating in the American College of Surgeons National Trauma Data Bank.

PARTICIPANTS

Adult patients with KD without lower extremity fracture.

INTERVENTION

Patients were grouped as ultra-low, low, or high-energy based on injury mechanism. Univariate/multivariate analyses assessed associations of energy level with NVI and of patient characteristics with NVI within energy-level groups.

MAIN OUTCOME MEASUREMENTS

Rate of nerve and blood vessel injury.

RESULTS

One hundred twenty-four patients with KD were identified; 181 sustained ultra-low-energy mechanisms, 275 low-energy, and 868 high-energy. Nerve injury occurred in 6% of ultra-low-energy injuries, 7% in low-energy, and 3% in high-energy (P = 0.03). Vessel injury occurred in 21% of ultra-low-energy injuries, 17% in low-energy, and 13% in high-energy (P = 0.01). On multivariate analyses, obesity was associated with nerve injury in the ultra-low-energy group (OR 4.9; 95% CI 1.0-24.0) but not with other energy levels. Obesity was also associated with vessel injury in the ultra-low-energy group (OR 4.0; 95% CI 1.6-9.7). Smoking, hypertension, and diabetes were not associated with NVI.

CONCLUSIONS

NVI following KD is more common after lower energy-level mechanisms. Obesity is associated with NVI in lower energy-level mechanisms. Physicians should be vigilant in screening for NVI in the setting of KD even with seemingly benign mechanisms of injury, especially in patients with obesity.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Epidemiology and outcomes of traumatic knee dislocations: Isolated vs multi-trauma injuries

BACKGROUND AND PURPOSE

Traumatic dislocation of the knee (TKD) is a rare injury, accounting for approximately 0.02% of orthopaedic injuries. They are a challenging entity for orthopaedic surgeons to manage, and can have devastating consequences. The aim of this study was to describe the epidemiology of traumatic knee dislocations (TKD'S) and contrast the incidence of neurovascular injury between isolated and multi-trauma dislocations as well as key patient reported outcomes achieved between these groups.

MATERIAL AND METHODS

Patients who had a traumatic disruption of the tibiofemoral articulation between March 1 2007 and February 31, 2015 were identified from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). Data was cross-checked with medical records and radiological reports to confirm true multi-ligamentous dislocation. VOTOR collects information pertaining to orthopaedic injuries, treatment, complications and outcomes from four adult hospitals in Victoria, Australia, including the major trauma centers. Patient-reported outcomes are collected by VOTOR at 12 months post-injury including the EQ-5D-3L (EQ-5D) and Glasgow Extended Outcome Scores (GOS-E) and return to work status. Patient reported functional and quality of life outcomes at 12 months after injury were analysed.

RESULTS

A cohort of 88 patients were identified that fit the inclusion criteria for the study, and at 12 months post-injury there was data available for 80 patients (90.9%). There were 38 (42.9%) patients who experienced an isolated traumatic knee dislocation and 52 (57.1%) who experienced a traumatic knee dislocation in association with another injury. Of the 88 patients identified as eligible for the study, two had bilateral knee dislocations, hence there were 90 multi-ligamentous knee injuries. Those who were injured at a higher velocity were more likely to have additional injuries. Dislocations that occurred at a lower velocity were shown to have better overall outcomes, as did dislocations that occurred in isolation.

CONCLUSIONS

Traumatic knee dislocations that occur in isolation typically result in better outcomes than those that occur with associated injuries. TKD's are a rare but severe injury that requires further research in order for functional outcomes to be optimized.

Surgical management of posterior knee dislocation associated with extensor apparatus rupture

OBJECTIVE

The purpose of this study was to report the clinical and functional results of patients who underwent surgical management for posterior knee dislocation associated with extensor apparatus rupture.

INTRODUCTION

Posterior knee dislocations associated with extensor apparatus ruptures are defined as rare but complicated injuries, which are difficult to return to the level of activity prior to the injury. The study demonstrated a hypothesis that good knee stability and early gain of range of motion could be achieved with deliberate design of the treatment protocol and proper application of the instruments.

METHODS

Fifteen patients with posterior knee dislocations associated with extensor apparatus ruptures were evaluated after reduction and repair of extensor apparatus. Following that, multiple-ligament reconstruction in association with use of a lateral knee-spanning external fixator was applied for at least six weeks. Ligament reconstructions were performed using allografts. Range of motion and knee stability were both measured at each follow-up evaluation at a mean time of 36months. The assessment was made using the Lysholm Knee Scoring Scale.

RESULTS

The mean Lysholm scale score was 87.6 (range 73-95), with excellent in 11 cases, good in two, and fair in two. In the final evaluation, the range of motion was a mean range of 123.4° (range 100-135).

CONCLUSION

The use of a lateral knee-spanning external fixator ensured the safety of repaired vessels, knee stability after reduction, and early rehabilitation with range of motion.

Early or delayed reconstruction in multi-ligament knee injuries: A systematic review and meta-analysis

BACKGROUND

Whether early or delayed surgical intervention in patients with multi-ligament injuries results in better outcomes, is of current and controversial debate.

PURPOSE

The purpose of this study was to perform a meta-analysis comparing early versus late surgical treatment of multi-ligament knee injuries.

METHODS

We performed a systematic review of Medline, Embase, Scopus, and Google Scholar to identify relevant studies in the English and German literature. Eligibility criteria included studies comparing early or delayed surgical interventions for multi-ligament knee injuries, with a minimum follow-up of two years, reporting the primary clinical outcome using a validated functional scoring system and range of motion. Exclusion criteria were patients treated with multi-trauma, head injury, non-union, lower extremity fractures, or a documented history of previous knee injuries. Publication bias was assessed by funnel plot, and the risk of bias was established using the Cochrane Collaboration's risk of bias tool. Heterogeneity was assessed using χ² and I₂ statistic.

RESULTS

Eight studies (n=260 patients) were included in the analysis. 149 patients were treated early with a mean of 10.6days; 111 patients were treated late with a mean of 294days. The pooled estimate for clinical outcome demonstrated that early surgery resulted in significantly higher Lysholm scores (SMD 0.669, 95% CI: 0.379 to 0.959, p=0.0001, I₂=0%). Thirty-one per cent of all patients with early surgery had a normal or near normal knee, whereas only 15% of patients with late reconstruction reported the knee to be normal or near normal. The pooled estimates for total ROM did not demonstrate a significant difference between the groups (SMD 0.113, 95% CI: -0.271 to 0.498, p=0.564, I₂=35.57%).

CONCLUSIONS

The results of this meta-analysis suggest that early surgical intervention in multi-ligament injuries of the knee produces a significantly superior clinical outcome, compared to late reconstruction. Although an overall trend of improved total range of knee motion was also demonstrated, this was very small and unlikely to be clinically relevant.

LEVEL OF EVIDENCE

Level 4; Systematic review and meta-analysis.

Current Concepts and Controversies in Rehabilitation After Surgery for Multiple Ligament Knee Injury

PURPOSE OF REVIEW

The purpose of this manuscript is twofold: (1) to review the literature related to rehabilitation after surgery for multiple ligament knee injury (MLKI) and after isolated surgery for the posterior cruciate ligament (PCL), posterolateral corner (PLC), and medial side of the knee and (2) to present a hierarchy of anatomic structures needing the most protection to guide rehabilitation.

RECENT FINDINGS

MLKIs continue to be a rare but devastating injury. Recent evidence indicates that clinicians may be providing too much protection from early weight bearing and range of motion, but an accelerated approach has not been rigorously tested. Consideration of the nature and quality of surgical procedures (repair and reconstruction) can help clinicians determine the structures needing the most protection during the rehabilitation period. The biomechanical literature and prior clinical experience can aid clinicians to better structure rehabilitation after surgery for MLKI and improve clinical outcome for patients.

An evidence-based algorithm for the management of common peroneal nerve injury associated with traumatic knee dislocation

Traumatic knee dislocation is a complex ligamentous injury that may be associated with simultaneous vascular and neurological injury.Although orthopaedic surgeons may consider CPN exploration at the time of ligament reconstruction, there is no standardised approach to the management of this complex and debilitating complication.This review focusses on published evidence of the outcomes of common peroneal nerve (CPN) injuries associated with knee dislocation, and proposes an algorithm for the management. Cite this article: Deepak Samson, Chye Yew Ng, Dominic Power. An evidence-based algorithm for the management of common peroneal nerve injury associated with traumatic knee dislocation. EFORT Open Rev 2016;1:362-367. DOI: 10.1302/2058-5241.160012.

Outcomes of surgical stabilization in patients with combined ACL deficiency and patellofemoral instability - A case series

BACKGROUND

The purpose of this study was to assess the disease-specific quality of life, and the objective clinical and functional outcomes of patients with symptomatic ACL deficiency and patellofemoral instability following surgical stabilization of both ligaments.

METHODS

Between February 2010 and August 2013, 22 subjects underwent a combined ACL reconstruction and patellofemoral stabilization. The anterior cruciate ligament quality of life questionnaire (ACL-QOL) was completed pre-operatively and two-years post-operatively. Clinical and functional assessments were performed two-years post-operatively. A paired t-test assessed the difference between the pre- and post-operative ACL-QOL scores. Effect size was calculated manually using the Eta squared formula. A Pearson r correlation coefficient assessed for a relationship between the post-operative ACL-QOL scores and functional tests.

RESULTS

Twenty patients completed the 24-month ACL-QOL, 17/20 completed clinical assessment, and 14/20 completed functional testing. The mean pre-operative ACL-QOL score was 21.20 (SD=7.25, range 5.8 to 31.7) and two-years post-operative it was 65.24 (SD=21.38, range 34.5 to 99.1). The paired t-test demonstrated a statistically significant improvement in ACL-QOL scores; t (19)=9.119, p<.001 (two-tailed). The Eta squared statistic (0.81) indicated a very large effect size. Statistically significant correlations (p<.05) were evident between post-operative ACL-QOL scores and all the operative limb single-leg hop tests.

CONCLUSIONS

Combined ACL reconstruction and patellofemoral stabilization surgery leads to good results. This patient cohort with chronic ACL-MPFL injuries demonstrated a statistically significant change in disease-specific quality of life following surgery. In addition, the patient-reported outcomes and objective functional testing results correlated.

LEVEL OF EVIDENCE

Case series - IV.

Radiographic assessment of the postoperative knee

Radiologists often encounter postoperative knee radiographs lacking any adjunct clinical data which might hinder accurate image interpretation. Surgical techniques are constantly evolving with new devices being used which make it sometimes challenging for the radiologist to deduce the performed procedure and to look for associated complications. This article reviews commonly performed surgical procedures of the knee, highlights their expected postoperative radiographic appearance and describes the appearance of certain postoperative complications.